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What I Would Do Differently

A time when OD/MD communication breakdown led to a dissatisfied patient.

It is safe to assume that, when errors are made involving two or more parties, poor communication is at the heart of the problem. In the era of electronic health records and burgeoning telemedicine—particularly in a field such as cataract surgery, in which optometrists and ophthalmologists routinely collaborate on patient care—open and secure means of communication should be at the foundation of practices that embrace such collaboration.

However, those of us in the trenches know the reality: Although we have obligatory forms in place to convey the necessary information, many times a phone call—or even a text message—is necessary to keep all parties involved in patient care up to date. To improve communication between eye care providers, it is sometimes useful to dissect a case in which communication didn’t work. By taking a step back, we can find the best steps to take forward.

A TALE IN THREE ERRORS

A patient presented to my office for cataract consultation, with the added desire to reduce dependence on spectacles and contact lenses. The patient was astigmatic. The patient reviewed a lifestyle questionnaire and expressed a desire for a multifocal IOL. No toric-multifocal IOL or toric extended depth of focus IOL was cleared by the US Food and Drug Administration at the time of the consultation. The patient and I had a lengthy conversation regarding the possibility of a LASIK enhancement to address the patient’s significant corneal astigmatism. The patient and I both expressed a general level of comfort with this plan, so a date was set for surgical intervention.

Error No. 1: The Surgeon Was Unaware of the Patient’s History.

In a letter back to the referring OD, I outlined my recommendation for a multifocal IOL with the potential for a LASIK enhancement to manage residual astigmatism. I happened to be speaking with the referring OD about another topic when our mutual patient became the subject of conversation. The OD relayed to me that, before the onset of the patient’s cataract, monovision contact lens correction was her preferred means of achieving spectacle freedom. We discussed potential treatment options and, in the interest of not rocking the boat, decided it was a good idea to offer monovision as an alternative to bilateral multifocal IOLs. I offered this option to the patient, and the suggestion was subsequently reinforced by the primary eye care provider.

How to prevent this error: We have a form that outlines the plan for surgery when the consultation is performed. We have the patient sign the same form again stipulating that the day of surgery there is no change to the plan, and they haven’t changed their intention for intervention.

Error No. 2: Mixed-up Terminology

The day of surgery for the nondominant eye was uneventful, and visual acuity on postoperative day 0 was J3. However, the patient expressed concerns about the type of IOL used. Terminology used by staff in the referring doctor’s office had suggested to her that the meanings of “astigmatism reduction” and “toric IOL” were nearly identical, much in the way that “facial tissue” and “Kleenex” have come to mean the same thing.

Despite her more than adequate near vision and our intent to reduce cylinder with femtosecond laser arcuate incisions rather than with a toric IOL, the patient was under the impression that a toric IOL was being purchased, and that this alone would address any astigmatism.

How to prevent this error: Communication is key, and nuance may be important for some patients. Keep this in during consultations.

Error No. 3: Inadequate Compensation Following Dissatisfaction.

Efforts made by my office and the primary eye care office to placate and educate the patient during the postoperative period were to no avail. I made the decision to give the patient a refund—despite the satisfactory surgical outcome—due to her lack of satisfaction. As part of the refund, the patient would forfeit any access to potential no-charge enhancements. Sure enough, several months later we received a letter requesting reimbursement for a planned laser vision enhancement, citing her desire to improve her near vision.

How to prevent this error: A well-defined consent form, an itemized list of what a patient is purchasing with the investment, and signature pages are helpful.  We chose to implement CheckedUp to validate the educational and verification process.

COMMUNICATION CONSISTENCY IS KEY

This cautionary tale offers a rationale for adhering to what Kevin Kelly has termed radical transparency1—an effort to share all relevant information with providers and patients alike.

For patients, in addition to traditional consent forms, we now employ immersive tools such as CheckedUp, which requires the patient to interact with educational materials detailing our practice’s clinical and surgical preferences and records the affirmation. For our comanaging providers, I encourage them to spend time with me in the OR and with the clinical team seeing preoperative candidates and postoperative patients. Doing so allows them to better understand the goals of each surgical technique and the nuances of language used when communicating the specifics of each procedure.

As optometry and ophthalmology work more closely together, it is crucial to stick to a single, coherent message, and lines of communication between primary eye care providers and surgeons must be solid. One way to prevent future patient complications is to make sure that each patient has a clear understanding of the big picture. We owe it to each other as eye care providers—and we owe it to our patients—to communicate clearly so as to provide the best care and outcomes.

author
Jonathan D. Solomon, MD
  • Editorial board member, CollaborativeEYE
  • Surgical and Refractive Director, Solomon Eye Associates, Bowie, Maryland
  • jdsolomon@hotmail.com
  • Financial disclosure: Consultant (Alcon, Allergan, Bausch + Lomb, Carl Zeiss Meditec, iOptics, LENSAR Laser, Zeimer); Investor (CheckedUp, Ocular Science, RPS)
  1. Kelly K. Out of Control: The Rise of Neo-biological Civilization. New York, New York: Basic Books; 1992.
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